1. Participants will be able to recognize the role of early exposure to the navigation of advance care planning conversations and palliative care needs of patients regardless of desired specialty in ...medicine.
2. Participants will be able to describe a model for teaching advance care planning for early career professionals through a train-the-trainer model
Nearly all healthcare providers will encounter a patient navigating serious illness at some point. We describe an initiative that leverages a peer train-the-trainer model to increase early learner comfort with advance care planning discussions.
With an aging population in the face of an annual loss of palliative care physicians, there is an increasing need for new providers to become well-versed in approaching goals of care of their patients. Medical students report limited exposure to and comfort with navigating patient goals of care, particularly as they pertain to end-of-life. 1,2 Formalized curricula for medical students have demonstrated the ability to increase comfort with broaching these important conversations with patients 3 Train-the-trainer models have been successfully utilized to improve communication of palliative care concepts in healthcare professionals. 4 We describe the utilization of this model to facilitate health professional student exposure and comfort with navigating discussions around advance care planning.
This project teaches medical students to learn to navigate conversations in advance care planning (ACP) with patients admitted to our institution utilizing an ACP worksheet that focuses on understanding what matters most to patients. After students complete an orientation where they both learn the fundamentals in ACP and have the opportunity to practice these conversations under the supervision of experienced students and faculty, they are eligible to attend weekly sessions where they navigate these same conversations with patients admitted to our institution. Student trainers guide more novice learners through conversations and facilitate post-session debriefing along with palliative care faculty.
We present the evolution of this initiative, including a sister initiative called The Companion Project, as well as student-surveyed perceptions of the initiative.
Not all medical curricula are created equal hence we aim to present a sustainable, scalable and easily implementable palliative care education initiative and its impact on participating students.
Models of Palliative Care Delivery; Resilience / Well being
Hospitals often lack bereavement programs. Bereaved families often navigate grief support on their own. This problem was complicated by the early COVID-19 pandemic.
Describe a cost neutral pilot to ...support next of kin (NOK) of deceased patients from our communicable disease response unit (CDRU) and palliative care unit (PCU).
pilot leveraging chaplains and a social worker (SW) to call NOK for grief support using a templated guide, referring interested NOK to bereavement support agencies.
NOK of patients who died in the CDRU and PCU at a metropolitan, quaternary care, hospital over five months.
One hundred eighty-six patients died. Eighty-one NOK were called, 51 calls were considered complete. Fourteen NOK accepted a referral for bereavement support.
This cost neutral pilot successfully connected 81 NOK with either a pilot chaplain or SW for bereavement support. Fourteen NOK accepted referral for a community bereavement resource.
1. Explain how the anterior cingulotomy procedure interferes with pain perception.
2. Describe the benefits of cingulotomy in our cohort including dramatic opioid dose reduction and decrease in ...reported pain scores.
Poorly controlled pain remains a common complication for patients with malignant cancer pain despite multimodal pharmacotherapy treatment options. To address this important quality-of-life issue, interventional procedures have received increased consideration. Anterior cingulotomy is a non- or minimally invasive neurosurgical procedure that creates lesions in the anterior cingulate cortex, an area of the brain that affects perception of pain. In case studies, cingulotomy has shown positive but variable effect for malignant pain and deserves further study in patients with medically refractory cancer pain.
We performed a retrospective chart review of all patients who underwent bilateral anterolateral surgical cingulotomy for refractory oncologic pain conducted at a single large academic quaternary care center in the southeastern United States between May 2019-2022. Main objectives were to assess (1) response to and (2) safety of this procedure in our cohort. For the first aim, we measured percent change of pain scores and average daily opioid dose reduction. For the second aim, complications were recorded. We also reported demographics, oncologic history, discharge disposition, and survival time postprocedure to better understand the study population.
Cingulotomy reduced pain scores with a concurrent dramatic reduction in opioid dosing in our cohort of patients with medically refractory malignant cancer pain and did not result in any major side effects. This suggests cingulotomy is an effective, safe, and potentially underutilized procedure for patients struggling with poorly controlled pain in the setting of advanced cancer.
Six patients with terminal cancer underwent seven total procedures. Average daily oral morphine equivalent (OME) dose 48 hours prior to procedure was 4,411 mg. At discharge, average daily OME dose was 240 mg, reflecting an 89% dose reduction. There was a pain score reduction of 43% between these same time points. There were no major complications. All patients discharged home.
Background:
There is a paucity of data evaluating utilization of palliative care in trauma intensive care units.
Aim:
We sought to determine current indications and determinants of palliative care ...consultation in the trauma intensive care units.
Design:
Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care.
Setting/participants:
A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma.
Results:
A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to board-certified palliative care physicians (χ2 = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were “giving up” (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician.
Conclusion:
Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services.
Background:
Primary palliative care (PPC) education programs have arisen in response to the recognition that all clinicians need to have a basic set of knowledge and skills to provide excellent care ...to all patients. PPC education programs appear to vary widely, making it difficult for potential learners to find the right program to fit their needs. We have cataloged and categorized a snapshot of PPC education programs across the United States to serve as a resource for those seeking training, and for educators interested in starting or optimizing such programs.
Methods:
Medical and commercial search engines (MSEs and CSEs, respectively) were used to generate a list of PPC education programs in the United States. Programs were contacted to supplement information available online, and then categorized based on intended learner, certification/degree conferred upon completion, and other characteristics.
Results:
There was little overlap between the PPC education programs found through MSEs and CSEs. Programs found via CSEs varied with respect to intended learners, pedagogy, content, and cost. Among the minority of programs that confer a certification/degree upon completion, there is no consensus as to what these signify.
Conclusions:
The wide variety of PPC education programs is both a challenge to and strength of the field. We hope that this report will serve as a call to develop a standard PPC education taxonomy to help define essential components of all PPC programs, while also leaving sufficient room for programs to serve the unique needs of their local learners and patient populations.
To determine the impact of a prospective, student-led, letter-based advance care planning (ACP) intervention on rates of ACP conversations and documentation among gynecologic oncology (GO) ...inpatients.
Retrospective analysis of patients admitted to the GO service at a single academic institution in 2019 showed that compliance with recommendations for ACP documentation was suboptimal. We initiated a quality improvement initiative from January through September 2020 to improve our compliance. Patients admitted to the GO service were given ACP packets with a letter-based advance directive (AD) worksheet modeled after the Stanford Letter Project. In January and February 2020, patients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. From March through September 2020, students were unavailable to facilitate in-person ACP conversations due to COVID-19 restrictions. Pre and post-intervention ACP documentation of patients admitted to the GO service were analyzed. Descriptive statistics were calculated, and associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression.
Since implementation of the letter-based ACP intervention, 98 patients were admitted to the GO service. The majority of those admitted had cancer (n=60, 61%). Only 16 patients (16%) had an AD on admission, and 65 patients (66%) reported never having an ACP conversation. Of 82 patients without ADs, 71 (87%) received an ACP packet. Of those receiving packets, 8 (11%) requested more information about ACP and 6 (8%) participated in an ACP conversation with a student. At 9-month follow-up among patients receiving a packet, 9 patients added an AD to their EMR (13%), and 2 updated their AD (3%). After the intervention, AD completion in our population went from 16% to 26%. Among those receiving ACP packets, increasing age was associated with increased post-admission AD completion (OR 1.1, p=0.01).
Completion of AD among patients continues to be low. Barriers to AD completion include patient and provider reluctance surrounding discussing these issues and difficulty with uploading these documents into the EMR. Letter-based ADs offer a unique method for introducing ACP earlier in cancer care and may lead to increased conversations about patient values and goals of care. More work is needed to improve occurrence and documentation of ACP conversations.
Older adults with advanced CKD have significant pain, other symptoms, and disability. To help ensure that care is consistent with patients' values, nephrology providers should understand their ...patients' priorities when they make clinical recommendations.
Patients aged ≥60 years with advanced (stage 4 or 5) non-dialysis-dependent CKD receiving care at a CKD clinic completed a validated health outcome prioritization tool to ascertain their health outcome priorities. For each patient, the nephrology provider completed the same health outcome prioritization tool. Patients also answered questions to self-rate their health and completed an end-of-life scenarios instrument. We examined the associations between priorities and self-reported health status and between priorities and acceptance of common end-of-life scenarios, and also measured concordance between patients' priorities and providers' perceptions of priorities.
Among 271 patients (median age 71 years), the top health outcome priority was maintaining independence (49%), followed by staying alive (35%), reducing pain (9%), and reducing other symptoms (6%). Nearly half of patients ranked staying alive as their third or fourth priority. There was no relationship between patients' self-rated health status and top priority, but acceptance of some end-of-life scenarios differed significantly between groups with different top priorities. Providers' perceptions about patients' top health outcome priorities were correct only 35% of the time. Patient-provider concordance for any individual health outcome ranking was similarly poor.
Nearly half of older adults with advanced CKD ranked maintaining independence as their top heath outcome priority. Almost as many ranked being alive as their last or second-to-last priority. Nephrology providers demonstrated limited knowledge of their patients' priorities.
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